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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O.BOX 388,304 EAST WEBER AVENUE,STOCKMN,CA 95201388 (209)488.3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED lCompleto Imtoj APPLICATION 19 HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ARI ND/OI INSTALL THE WORE DESCRIBED.THIS APPLICATION t@ MADE IN COMPUANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE@,ENVIRONMENTAL HEALTH DIVISION. _ _/00- JOB ADORE99/OR APHI 2j G CITY Ji 'SIZFJAP4e re OWNER'S NAME A�i P7 I �.�[%r �9 a ADDRESS U2:32-N/wt �-/�UP�"-�cr'!��e N PHONE t _4 7 7- 3,171 CONTRACTOR / �l e i ADDRESS �/Y{Io('.SrdOL/A 9574E LIC@ )G� y ) PONE%I ) - •'(i�/Q SUS CONTRACTOR /I LU/V 4 ADORES/ LUC/ PHONE t TYPE OF WEWPUMP '❑NEW WLLL ❑REPLACEMENT WELL ❑MONITORING WELLS ❑OTHER ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑C11085-CONNECT REPAIR ❑VAPOR EXTRACTION WELLS RYPE OF PUMP ❑Naw❑Repair H.P. DEPTH PUMP SET_FT, FIRST WATER LEVEL G ❑OVf-0E-SERIC VE WELL 13OEOPHHYSICAL WELL S J"L SOIL BORING 6 S @ 11 DESTRUCTION: INTENDED { YPE F W wn.tntrr/tarn e.ciwcAi___ - '1/ A 13 INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 2" DIA.OF CONDUCTOR CASINO AVIA- O ❑DOMESTICIPIIIVATE ❑GRAVEL PACK/e1ZE TYPE OF CAe1NORTEEUPVC_ ik,&4 DIA.OF WELL CASINO A)'1A O ❑PUBLIC/MUNICIPAt. ❑DRIVEN DEPTH OF GROUT BEAL �r//`JCt_ SPECIFICATION /FI R p❑IRRIGATION/AG ❑OTHER GROUT TEAL INSTALLED yBY CTYTutj,I -I'2y,Ay✓ GROUT BRAND NAME /114 E El MONITORING ,L,` GROUT SEAL PUMPED:11 Y. (M Ne CONCRETE PEDESTAL BY DRILLER:Illy- C]Ne S APPROX.DE►TH 4o I LOCKING CHESTER BOX/STOVE PPE__,64�� PROPOSED CONSTRUCTION/DRIWNG METHOD:MUD ROTARY AIR FIOTARY AUGER CABLE OTHEIL k"/ S 114MBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK.WILL SE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAW$.ANO RULE@ AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AOENT'9 SIGNATURE CERTIFIES THE FOLLOWING:•1 CERTIFY THAT IN THE PEKORMANCE OF THE WOIK FOR WHICH THIS PERMIT to ISSUED,1$HALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.'CONTRACTOR'S HIRING OR 9UW RMAV1Ci1N0 SIGNATURE CERTSIE$ THE FOLLOWINO: '1 IFY TH/� IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSON$SUBJECT TO WORgMAM't COMPdtATOM LAWS OF CAUFOR/IA.' THIS ANT IT CALL HquI.IN ADVANCE FOR ALL REQUIRED INS TON{AT I"s)4pJetS.COMPLETE DRAWING SUB AT LOWER W AREA PROVIDED. 9ipmd x ' TitH �sL.`/j PLOT PIAN IN—to SWe)$eate�_•bS,�jp�yl 1. HAM ES OF $OR ROADS NEAREST TO OR BOUNCING THE PRO PERTY, 4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2.OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DISSECTION. EXPANSION OF SEWAGE OISPO$AL WREN$. t.DIMENSION OUTLINES AND LOCATION OF ALL EXIsyNUb AND PROPOtEO $.LOCATION OF WELLS WITHIN RADRU$OF ONE HUNDRED FIFTY Ft. STRUCTURES,INCLVDINO COVERED AREAB SUCH AS PATIO$,DRIVEWAYS,AND WALK$. ON THE PROPERTY OR ADJOINING PROPERTY. r 42 t N ..c o a o� j c `. 2405 c. 40 tr 2.M � • I E AS E T ~ g agL A .... J ..( V P A 494'' 8" V LObe locations Q N N < "' U co (o .p 0) Y� Nip 2320 i... . Iv r. 0VrIp VI 2. c W DA SS E ADA � S Y' to a i . , .. .:.. ..:... .i......... .... ' "TMINT USE ONLY Application Aeeepied BY L'/�/(// �/�` c" �w Grout Impootlen By EEE Ome Pimp Impeelen By •-�/ O.H. Deattueilen Impaction By Dab CeG //h /a a ACCOUNTING ONLY: AIOS TACO PE CODES FEE INFO AMOUNT..11. .HEC ASH RECEIVED BY DAT PUMMTRDNICE REDUFJT NLUBIN INVOICE anfIO Ol/S l I, . 8 c •